01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-01-22 | 11 | 2025-01-22 | 11 |
| Cycle 2 | 2023-07-13 | 11 | 2023-07-13 | 15 |
| Cycle 3 | 2022-06-16 | 14 | 2022-06-16 | 10 |
CMS CCN 0651662026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Poudre Canyon Rehabilitation And Nursing, Llc
1000 S Lemay Ave · Fort Collins, CO 80524 · Larimer County
Certified beds83CMS provider file
Recent citation rows72current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
72 rows in the current release
5 rows carry G–L scope/severity codes; 1 carry J–L. 19 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-05-15 · HEALTHF0600Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-05-16 · complaint2025-05-15 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-05-16 · complaint2025-05-15 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-05-16 · complaint2025-05-15 · HEALTHF0760Severity G · isolated actual harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-05-16 · complaint2025-01-22 · HEALTHF0600Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-02-19 · complaint2025-01-22 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-02-19 · complaint2025-01-22 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-02-06 · complaint2025-01-22 · HEALTHF0700Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Correction field: Deficient, Provider has date of correction · 2025-01-23 · complaint2025-01-22 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-22 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-22 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2025-02-062025-01-22 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-02-152025-01-22 · HEALTHF0867Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2025-02-142025-01-22 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-02-062025-01-22 · HEALTHF0921Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2025-02-192025-01-22 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2025-03-082025-01-22 · FIREK0293Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2025-03-082025-01-22 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Waiver has been granted · 2026-06-012025-01-22 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-03-312025-01-22 · FIREK0355Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2025-03-312025-01-22 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-03-312025-01-22 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Waiver has been granted · 2025-11-212025-01-22 · FIREK0541Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Install properly constructed and protected linen or trash chutes.
Correction field: Deficient, Provider has date of correction · 2025-03-142025-01-22 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-02-1803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-05-15 | Fine | $10,358 | 0 |
| 2025-01-22 | Fine | $37,950 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHARLY BELLO FAMILY LIMITED PARTNERSHIPOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- MAZE FAMILY LIMITED PARTNERSHIPOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- PICKD LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- MAHRT, DAVIDIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- MYERS, KATIEIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- MYERS, WALTERIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- SWAIN, HOLLYIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- SWAIN, JAREDIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- COTTONWOOD HEALTHCARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- BADER, CARLYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- MYERS, WALTERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- BADER, CARLYIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/10/2025
- FRASER, MALCOLMIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/10/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.65per resident day
RN hours0.48per resident day
Weekend nurse hours2.51per resident day
Staff turnover60.5%CMS reported field
06 / LOCAL RECORDS
Open the Fort Collins ledger →Other published facilities nearby
Centre Avenue Health And Rehab Llc90 beds · CMS overall 5/520 citation rowsColumbine West Health And Rehab Llc100 beds · CMS overall 3/523 citation rowsCreekside Village Rehabilitation And Nursing Llc120 beds · CMS overall 1/584 citation rowsGood Samaritan Society -- Fort Collins Village64 beds · CMS overall 4/522 citation rowsLemay Avenue Health And Rehab Llc130 beds · CMS overall 4/519 citation rowsRehabilitation And Nursing Center Of The Rockies106 beds · CMS overall 3/533 citation rowsStorybrook Care & Rehabilitation60 beds · CMS overall 1/552 citation rows